HIV: Opportunistic infections, treatment of Pneumocystis carinii

Several treatment schemes are possible.

• 1st choice: Intravenous or oral trimethoprim/sulphamethoxazole (= cotrimoxazole, Bactrim®, Eusaprim®) 4 x 3 ampoules IV per day or 6-8 Bactrim forte® tablets per day. If there is no pronounced dyspnoea, the treatment can be given all orally. Side-effects of the medicaments occur frequently (allergic reactions with cutaneous abnormalities).

• 2nd choice: Oral dapsone/trimethoprim (Dapson® 100 mg/day + Wellcoprim® 20 mg/kg/day divided over 4 doses). With less serious PCP 100 mg dapsone is administered together with TMP (trimethoprim) 3 x 300 mg/day.

• 3rd choice: Pentamidine (Pentacarinat®) IV. The guide dose is 4 mg/kg in one administration over 8 hours in a 5% glucose infusion.

• 4th choice: Pentacarinat® in 300 mg aerosol in 6 ml sterile water. It is advised to give salbutamol puffs beforehand.

• Alternatives: other medicaments are clindamycin + primaquine, atovaquone and trimetrexate (Neutrexin®). The duration of the treatment is 21 days.

In case of severe hypoxia intravenous steroids (methylprednisolone) should be given. The patient may exhibit a hypersensitivity reaction due to the release of large quantities of antigenic material from the organisms. At later stages, corticosteroids are no longer effective.

A relapse frequently occurs after discontinuing a "curative" treatment. Prophylaxis is therefore given after the initial treatment. The same medicaments but in lower dose (Bactrim forte® 1 per day; or dapsone 100 mg/day) PO or 300 mg pentamidine-aerosol once a month can be used. Fansidar® 1 tablet per week can also be given. Cotrimoxazole acts simultaneously as a prophylactic agent for toxoplasmosis. Dapsone can be tried when cotrimoxazole is not tolerated.

Category: Medical Subject Notes , Medicine Notes , Pharmacology Notes